Tilburg University
Effectiveness of teamwork in an integrated care setting for patients with COPD
van Dijk-de Vries, A.N.; Duimel-Peeters, I.G.P.; Muris, J.W.M.; Wesseling, G.J.; Beusmans,
G.H.M.I.; Vrijhoef, H.J.M.
Published in:
International Journal of Integrated Care
DOI:
10.5334/ijic.2454
Publication date:
2016
Document Version
Publisher's PDF, also known as Version of record
Link to publication in Tilburg University Research Portal
Citation for published version (APA):
van Dijk-de Vries, A. N., Duimel-Peeters, I. G. P., Muris, J. W. M., Wesseling, G. J., Beusmans, G. H. M. I., & Vrijhoef, H. J. M. (2016). Effectiveness of teamwork in an integrated care setting for patients with COPD: Development and testing of a self-evaluation Instrument for interprofessional teams . International Journal of Integrated Care, 16(1), [9]. https://doi.org/10.5334/ijic.2454
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Van Dijk-de Vries, A N et al 2016 Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD: Development and Testing of a Self-Evaluation Instrument for Interprofessional Teams. International Journal of Integrated Care, 16(1): 9, pp. 1–10, DOI: http://dx.doi.org/10.5334/ ijic.2454
* Department of Family Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands; Department of Social Medicine, CAPHRI School for Public Health and Primary Care, Maastricht University, Maastricht, The Netherlands
† Department of Family Medicine, CAPHRI School for Public
Health and Primary Care, Maastricht University, Maastricht, The Netherlands; Department of Patient & Care, Maastricht University Medical Center, Maastricht, The Netherlands
‡ Department of Family Medicine, CAPHRI School for Public Health and
Primary Care, Maastricht University, Maastricht, The Netherlands
§ Department of Respiratory Medicine, CAPHRI School for Public
Health and Primary Care, Maastricht University Medical Center, Maastricht, The Netherlands
ǁ Saw Swee Hock School of Public Health, National University
Singapore, National University Health System, Singapore, Singapore; Department Patient & Care, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Family Medicine and Chronic Care, Vrije Universiteit Brussels, Brussels, Belgium
b.vrijhoef@mumc.nl
Corresponding author: Hubertus J. M. Vrijhoef
RESEARCH AND THEORY
Effectiveness of Teamwork in an Integrated Care Setting
for Patients with COPD: Development and Testing of a
Self-Evaluation Instrument for Interprofessional Teams
Anneke N. Van Dijk-de Vries
*, Inge G. P. Duimel-Peeters
†, Jean W. Muris
‡,
Geertjan J. Wesseling
§, George H. M. I. Beusmans
†and Hubertus J. M. Vrijhoef
ǁIntroduction: Teamwork between healthcare providers is conditional for the delivery of integrated care. This study aimed to assess the usefulness of the conceptual framework Integrated Team Effectiveness Model for developing and testing of the Integrated Team Effectiveness Instrument.
Theory and methods: Focus groups with healthcare providers in an integrated care setting for people with chronic obstructive pulmonary disease (COPD) were conducted to examine the recognisability of the conceptual framework and to explore critical success factors for collaborative COPD practice out of this framework. The resulting items were transposed into a pilot instrument. This was reviewed by expert opinion and completed 153 times by healthcare providers. The underlying structure and internal consistency of the instrument were verified by factor analysis and Cronbach’s alpha.
Results: The conceptual framework turned out to be comprehensible for discussing teamwork effectiveness. The pilot instrument measures 25 relevant aspects of teamwork in integrated COPD care. Factor analysis suggested three reliable components: teamwork effectiveness, team processes and team psychosocial traits (Cronbach’s alpha between 0.76 and 0.81).
Conclusions and discussion: The conceptual framework Integrated Team Effectiveness Model is relevant in developing a practical full-spectrum instrument to facilitate discussing teamwork effectiveness. The Integrated Team Effectiveness Instrument provides a well-founded basis to self-evaluate teamwork effectiveness in integrated COPD care by healthcare providers. Recommendations are provided for the improvement of the instrument.
Keywords: Teamwork; integrated care; self-evaluation; instrument; psychometric properties Introduction
The care of people with long-term conditions is universally recognised as a major challenge to health care services [1]. Chronic obstructive pulmonary disease (COPD) will be a leading cause of morbidity and mortality worldwide by 2020 [1]. COPD is defined as a preventable and treatable disease state, characterised by a progressive airflow limita-tion that is not fully reversible [2]. Improvements in quality of life, reduction in the rate of decline in lung function, and
prevention and treatment of exacerbations involve a wide range of skills and activities, which can only be provided when different healthcare providers from both primary and secondary care work together with patients [3]. Innovative integrated care models are being explored in order to provide cost-effective chronic care to meet local needs [4–6].
have become essential requirements for the provision of high-quality care [5–7]. To deliver high-quality, evidence-based chronic care to those patients at greater risk, the presence of a multidisciplinary team was found to be associated with more comprehensive service provision [8–9].
For healthcare providers to work as a team, it is not enough to put them together and expect that they will automatically know how to work collaboratively [10–12]. Economic and historical political factors may affect the effectiveness of multidisciplinary teamwork as well as the interprofessional nature of the healthcare team [13–14]. Therefore, team effectiveness is a complex and multifaceted construct. Literature reviews and available instruments show the numerous dimensions and aspects of teamwork effectiveness, indicating the careful process of selecting an instrument to measure team effectiveness [11–13–15–18].
As indicated by Reeves et al. [17], among various models outlining the key elements that contribute to team effectiveness (i.e. how well a team functions), only the Integrated Team Effectiveness Model ‘has acknowl-edged the wider systems factors on teamwork’ (p. 50). Furthermore, according to Integrated Team Effectiveness Model, the effectiveness of a healthcare team depends on the determinants of the following domains: the socio-political context in which the team exists, the organisa-tional context in which the team is doing its work, the task design, the team process and the psychosocial traits of the team. Integrated Team Effectiveness Model is an integrated framework that can be tailored to specific types of teams and settings [19]. As such, Integrated Team Effectiveness Model possesses important features when focussing on integrated care, as is the case in the current study.
This article outlines the process in developing and pilot testing a new instrument, the Integrated Teamwork Effectiveness Instrument, designed to measure healthcare team professional members’ perception of working col-laboratively. This study aimed: (1) to assess the usefulness of the Integrated Team Effectiveness Model for develop-ing a valid and practical instrument for self-evaluation of teamwork effectiveness by professionals and (2) to assess the content validity of Integrated Teamwork Effectiveness Instrument in measuring the perceived effectiveness of healthcare professionals working together in the care for people with COPD in the Maastricht region, the Netherlands.
Theory and methods Theoretical background
In discussing the differences in how professional teams work, Reeves et al. made a distinction between teamwork, collaboration, coordination and networking [17]. They view teamwork as the most focussed form with high levels of interdependence, integration and shared responsibil-ity. The other three approaches are increasingly broader activities with reducing levels of interdependence and so on. Notwithstanding the tentative nature of this typology,
‘it begins to indicate how different types of interprofes-sional teamwork can be considered contingent on the nature of responding to local need’ [17, p. 45]. Interpro-fessional teams in health and social care come into exist-ence to ensure that professions can complete a care task, or a combination of tasks, that they could not achieve so effectively on their own [17].
Interprofessional teams vary in how well they function. In their summary of factors influencing team effectiveness, Reeves et al. pointed out that of models indicating factors that may influence team effectiveness, Integrated Team Effectiveness Model is the only framework considering factors at the systems level in addition to factors at the practice level and the organisational level [17].
Integrated Team Effectiveness Model is based on an extensive literature review [19] and uses Cohen and Bailey’s [20] team typology and team effectiveness model as a starting point for conceptualising health-care team effectiveness. According to Cohen and Bailey, a multidisciplinary team can be defined as ‘a collection of individuals who are independent in their tasks, who share responsibility for outcomes, who see themselves and who are seen by others as an intact social entity embedded in one or more larger social systems and who manage their relationships across organisational boundaries’ [20]. Consequently, ‘teamwork’ is the product of interactions between healthcare profession-als in a team.
Integrated Team Effectiveness Model depicts the com-plex interactions between task design, team processes, team psychosocial traits and team outcomes. Task design includes the type of team (e.g. project management and care delivery), task features (e.g. interdependence and autonomy), team composition (e.g. size and discipline) and organisational context (e.g. rewards and supervision). Task design factors can be manipulated by managers to improve team effectiveness. Team processes (e.g. com-munication and conflicts) are distinguished from team psychosocial traits (e.g. norms and shared mental modes). Both processes and traits are group-level phenomena that are influenced by task design and that can directly influ-ence team outcomes; in addition, team processes and traits interact with each other. Task design can influence outcomes directly or indirectly [19]. Furthermore, the fac-tors grouped under task design, team processed and team psychosocial traits play out on practice or team level, organisational level, and systems level and together deter-mine the effectiveness of the teamwork [17].
Van Dijk-de Vries et al: Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD Art. 9, page 3 of 10
that identify the essential indicators of team effective-ness in health care [19]. Distinguishing between objective (whether the goals of the team are achieved) and subjective outcomes (whether the team in itself works well together) is important considering that for the delivery of integrated care the formation of teams is still work in progress.
Notwithstanding the attractiveness of Integrated Team Effectiveness Model as a conceptual framework to the field of integrated care, it has not yet been translated into an instrument to be used by healthcare professionals to self-evaluate the effectiveness of their teamwork.
Study setting
The integrated care setting for COPD patients in the Maastricht region includes one university hospital and 82 general practitioners working in 60 general practices. The multidisciplinary collaboration turned out to be a relevant issue for all COPD healthcare providers because a bundled payment system has been rolled out for COPD care in the Maastricht region. In brief, a bundled pay-ment makes it possible for different elepay-ments of COPD care to be purchased, delivered and billed as a single product of service [21]. The services to be included have been described in a disease-specific healthcare standard. The development of the instrument was undertaken dur-ing the implementation phase of the bundled payment for COPD care; hence, the level of collaborative practice was variable between general practices. Nevertheless, participants were already familiar with the concepts of integrated care owing to a bundled payment for diabetes mellitus type 2 [21], joint consultations between the gen-eral practitioners and pulmonologists [22] and a chronic care programme for patients with asthma or COPD [23].
Sample and procedure
The study was conducted in two phases. In phase 1 Inte-grated Team Effectiveness Model was applied to inte-grated COPD care and translated into a teamwork evalu-ation instrument. Phase 2 included an exploratory factor analysis for psychometric testing of the instrument.
Phase 1 – Instrument development
Conducting focus groups was the first step of instrument development [24, 25]. The purposes of the focus groups were to examine the recognisability of Integrated Team Effectiveness Model and to explore all critical success
factors for collaborative COPD practice based on this framework. Open-ended questions that covered the domains of Integrated Team Effectiveness Model [19] were used to initiate the conversation (see Table 1). A random sample of 26 general practitioners in the Maas-tricht region was invited to participate in the study. Due to perceived differences between collaborative practice in solo and groups practices [26], two focus groups met sepa-rately: general practitioners from solo and duo practices (n = 7) and general practitioners working in group practices (n = 4). Three out of four practice nurses, already involved in COPD care, volunteered to participate in a focus group. The focus group of respiratory nurse specialists consisted of four out of six participants. During the research pro-ject, one pulmonologist was involved in integrated care delivery, crossing the borders of primary and second-ary care. This specialist was interviewed individually. All discussions were audio taped and transcribed verbatim.
Following the focus groups, an analysis was carried out about primary indicators to be included in the instru-ment. Key stages followed were: familiarisation with the data, managing the data, mapping and interpretation [25]. The analysis was discussed among all members of the research team. In doing so, the generated topics in the concept instrument were compared with two literature reviews about teamwork to ensure that the items indicate determinants of effective collaborative practice [12, 13]. Member check was accomplished by a multidisciplinary expert panel of COPD healthcare providers (n = 8). These healthcare providers were involved in the focus groups. The expert panel was asked to review the instrument; specifically, it was requested to analyse whether the items covered all the important areas and if the wording of the items was succinct. The panel also considered the practi-cal use of the instrument. The feasibility of the instrument was verified by a pretest in one COPD team. This enabled the leading author to attend the teamwork evaluation dia-logue guided by the instrument.
The Integrated Teamwork Effectiveness Instrument is oriented towards the healthcare providers’ perception of team-work effectiveness. For this reason, the indicators from the focus groups were reformulated into statements with answer choices on a 4-point Likert scale (rang-ing from strongly disagree to strongly agree). The items were phrased both positively and negatively. If a par-ticular item did not apply, one could choose the answer
Domain Integrated Team
Effectiveness Model Question
Team effectiveness What will effective teamwork in COPD care bring in and how can we measure that?
Organisational context How do you define an organisational context with incentives for effective teamwork in COPD care?
Task design How do you define your role in the COPD team?
Team processes How do you define basic criteria for an effective team process considering the following key
words: communication, collaboration, coordination, conflict, leadership, decision-making and participation?
Team psychosocial traits What characteristics are required in a COPD team to be involved in the team and how important is that?
‘not applicable’. For facilitating discussion, respondents pointed out relevant issues for their team (‘important to discuss in our team: yes/no’ – for every particular item). Teams were asked about their ability to use the instru-ment without the presence of an outside consultant.
Phase 2 – Psychometric evaluation
Initial psychometric evaluation of the Integrated Team-work Effectiveness Instrument included an exploratory factor analysis using the method of principal compo-nents [27]. The aim was to reduce data to a smaller set of components and to compare these dimensions with the underlying conceptual framework. In order to conduct a statistically meaningful factor analysis, it was aimed to include minimal 125 respondents to reach five subjects for 25 items [27].
First, all COPD practice nurses (n = 28; with exception of those in the team of the initial testing in phase 1) in the Maastricht region were requested to invite their COPD team for a teamwork self-assessment dialogue. They received the instrument with instructions by email. The team dialogue took place in the presence of at least a general practitioner and a practice nurse. Dependent on the level of teamwork in the general practice, practices nurses invited the nurse specialist, physiotherapist and/ or dietician. The pulmonologist would complete the ques-tionnaire, but for practical reasons he was not expected to attend all the team meetings during the pilot study.
To maximise the response and to enable psychometric testing of the instrument, individual core members of the COPD team (i.e. general practitioner, practice nurse, pul-monologist and respiratory nurse) were invited to com-plete the questionnaire without discussing it within their teams. Healthcare providers were requested to complete the questionnaire for the team(s) they were involved in. Data analysis
Data were analysed using SPPS version 15.0 (SPSS Inc., Chicago, IL). Given that the Integrated Team Effectiveness Model suggested different factors of team effectiveness to be dependent, a factor analysis with oblique rotation was applied to the 25 items. Tests of sampling adequacy (Kaiser–Meyer–Olkin (KMO)) and multicollinearity (Bart-lett test of sphericity p < 0.05) were undertaken to check that the scale items were appropriate for factor analysis. The answer option ‘not applicable’ was treated as miss-ing value. Pairwise deletion procedure was used to avoid extensive loss of responses due to single-item missing val-ues. In total, there were 150 missing valval-ues. The number of missing cases on each variable is small relative to the sample size (1–20 missing values per variable, mean 6.0, ±6.1). Under listwise deletion technique, the sample size would have been n = 91.
The number of factors was assessed by Horn’s parallel analysis, which selects the factors that are greater than random [27]. Individual items were evaluated for inclusion or exclusion based on correlations, factor loading (greater than 0.35 [27, 28]) and the logical interpretability of the item in relation to the extracted factor. For each scale emerging from the factor analysis, internal consistency
using Cronbach’s alpha coefficients was calculated. A Cronbach’s alpha score of 0.7 or higher is usually regarded as indicative of acceptable reliability [27, 28]. Results
Phase 1 – Instrument development
The focus group members were able to translate every domain of Integrated Team Effectiveness Model into their daily practice. Each discipline stressed specific issues. The main differences between healthcare professionals relate to their scope of practice or their collaborative experience in COPD care. The indicators listed in Table 2 are the pri-mary themes of teamwork effectiveness elicited by the interviews.
An expert panel of eight COPD healthcare profession-als (three general practitioners, one pulmonologist, two practice nurses and two respiratory nurses) considered the instrument to be a useful and relevant checklist for discussing team effectiveness. They added one item about keeping an overall perspective of the person in addition to his/her COPD. The test panel was a COPD team includ-ing a general practitioner, practice nurse, two dieticians and two physiotherapists. They came to agreements about how to improve the registration and communication pro-cess. Their feedback led to revised procedures concerning the instrument. The final pilot instrument consisted of 25 items concerning organisational context, task design, team process, team psychosocial traits and team effective-ness. The word ‘team’ was found confusing for healthcare providers because: 1) they work in different ‘teams’ for different types of COPD patients and 2) they work on a (physical) distance of each other in various teams. For this reason it was decided to replace the word ‘team’ with ‘col-laborative’ (in Dutch: samenwerkingsverband) to point out a group of healthcare providers that have a shared responsibility for the delivery of care to a population of patients with COPD.
Phase 2 – Psychometric evaluation
Out of the 28 teams involving practice nurses, five of them organised a team evaluation meeting. These five teams brought in 21 questionnaires. In the second phase of data collection, 140 questionnaires were returned. Eight health-care providers did not complete the questionnaire (more than half of the items were missing) as they stated to lack experience working in the COPD team. The pulmo-nologist and three respiratory nurses only evaluated the COPD teams they were involved in (respectively 27 and 29 of 55 COPD teams). Eight practice nurses were working for two general practices. They evaluated the collabora-tion within these COPD teams separately. The final sample consisted of 153 questionnaires completed by 93 COPD healthcare providers (Table 3).
Factor analysis
Van Dijk-de Vries et al: Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD Art. 9, page 5 of 10
Domain Integrated Team Effectiveness
Model Focus groups
Organisational context
Goals/standard The collaborative practice aims to improve patients’ quality of life
Structure/characteristics Clarity about structure and agreements of collaborative practice
No competition among team members
Rewards/supervision Team members are accessible for consultation
Training Environment There are adequate training opportunities
Resources The availability of time and work places
Information System The information system is functioning and add relevant data
Task design
Interdependence Team members are interdependent to deliver quality of care
Autonomy The input of every team member is valued
Clarity of rules and procedures In general, the team will follow the care protocols.
Team process
Communication Relevant patient data are exchanged
Team meetings are effective
Coordination Communication contributes to continuity of care
Decision-making A decision to be off track will be discussed within the team
Participation Team members give priority to team meetings
Conflict Open communication is valued
Team psychosocial traits
Cohesion Personal involvement in a COPD team
Norms Mutual respect and trust between team members
Team effectiveness
Objective outcomes
Patient Several indicators (e.g. exacerbation and quality of life) which are not only a
determinant of teamwork Patient drop-out
Subjective outcomes Patients know their primary contact person
Perceived team effectiveness Satisfaction about the joint contribution to patients’ quality of life
The care is patient-centred, not only disease specific The team has an overview about their patients
Table 2: Integrated Team Effectiveness Model applied to integrated care for people with COPD.
Discipline Number of respondents Response rate (%) Number of questionnaires
General practitioner 53 65 53 Practice nurse 32 71 40 Pulmonologist 1 100 27 Respiratory nurse 3 60 29 Dietician 3 NA 3 Physiotherapist 1 NA 1 Total 93 NA 153
did not correlate with any other variable (r < 0.3) and the majority of p values were greater than 0.05. The item lim-ited the interpretability of the underlying constructs and the reliability of the scales. Twenty-four items were left to be used in the factor analysis. The results are reported in Table 4. The average communality was 0.46 (± 0.10, range: 0.25–0.62).
The factor analysis identified a 24-item questionnaire with three components of team effectiveness. The eigen-values for the three components were 7.21, 2.06 and 1.68, respectively. These components explained 46% of the variance (30.06, 8.60 and 7.01, respectively). The first sub-scale measures different aspects of perceived team effec-tiveness. The second subscale involves in essence aspects
Item Cs*
Component
1 2 3
Component 1 In our COPD . . . .
4 0.51 . . . the electronic system for sharing data contributes to our teamwork 0.75 −0.01 −0.20
24 0.45 . . . The drop out of COPD patients is low 0.67 0.01 −0.02
25 0.44 . . . we not only focus on the disease but keep an overall picture of the patient 0.63 −0.21 0.17
23 0.39 . . . we have a better overview of our COPD patients due to our teamwork 0.55 0.00 0.17
22 0.42 . . . patients know their personal contact point 0.51 0.25 0.07
13 0.52 . . . we are providing patient data which are relevant for team members 0.47 0.27 −0.05
21 0.62 . . . I feel that we jointly are doing a good job in meeting patients’ care needs 0.45 0.21 0.41
9 0.25 . . . there are adequate opportunities to increase our knowledge about COPD 0.34 0.20 0.13
Cronbach’s alpha = 0.80 (7 or 8 items) Component 2
In our COPD-team . . . .
5 0.59 . . . there is not enough available time for each other −0.11 0.81 −0.21
2 0.54 . . . the different roles and responsibilities needs to be more clearly defined −0.02 0.72 0.06
7 0.54 . . . the consultation function of team members needs to be more accessible 0.14 0.68 0.01
16 0.29 . . . we need more communication to provide continuity of care 0.31 0.56 −0.17
14 0.42 . . . team meetings are easily cancelled −0.17 0.55 0.30
10 0.40 . . . we accomplish each other (vision, knowledge and skills) 0.21 0.41 0.23
12 0.48 . . . reasons to deviate from protocol are discussed 0.33 0.38 0.25
Cronbach’s alpha = 0.76 (7 items) Component 3
In our COPD team . . . .
18 0.64 . . . team members feel that they are valued and respected 0.14 −0.20 0.78
17 0.51 . . . I know I can rely on the expertise of my team members 0.03 0.07 0.68
8 0.30 . . . competition interfered with my collaborative work 0.01 −0.10 0.56
19 0.52 . . . our communication is characterised by openness 0.37 −0.08 0.54
6 0.29 . . . a need for proper work rooms is impeding our team functioning −0.27 0.12 0.52
1 0.45 . . . we are working towards a common purpose 0.29 0.03 0.51
20 0.36 . . . I consider myself as a member of this team −0.01 0.30 0.45
11 0.54 . . . members of the team feel that their expertise is fully utilised 0.32 0.33 0.38
3 0.52 . . . we have well understood work agreements 0.30 0.34 0.37
Cronbach’s alpha = 0.81 (9 items)
Table 4: Communalities, component loadings of the PCA and Cronbach’s alpha.
Van Dijk-de Vries et al: Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD Art. 9, page 7 of 10
of the team process. The third subscale mainly contains items of the teams’ psychosocial traits.
As we used a minimum cut-off of 0.35, item 9 about increasing knowledge did not sufficiently load on a com-ponent. Item 21, ‘I feel that we jointly are doing a good job in meeting patients’ care needs’, measures team effec-tiveness (0.45) and team psychosocial traits (0.41). Item 19, ‘our communication is characterised by openness’, is loading on team psychosocial traits (0.54) as well as team effectiveness (0.37). Cronbach’s alpha for the three com-ponents was 0.80, 0.76 and 0.81, respectively. The internal consistency of component 3 increased from Cronbach’s alpha = 0.81 to alpha = 0.82 by deletion of item 6.
Discussion
The conceptual framework Integrated Team Effectiveness Model was found to be relevant in developing a practical full-spectrum instrument to self-evaluate teamwork effec-tiveness. Healthcare providers recognised the domains of Integrated Team Effectiveness Model and were able to apply them into their daily practice, although the adop-tion of multidisciplinary teamwork in COPD care was in its infancy during the study. The Integrated Teamwork Effec-tiveness Instrument provides a well-founded basis for dis-cussing the effectiveness of teamwork in integrated care for people with COPD. Integrated Teamwork Effectiveness Instrument counts 24 items and 3 complementary sub-scales of team effectiveness with acceptable coefficients of reliability (Cronbach’s alpha ranging from 0.76 to 0.81). The sub-scales correspond to the following domains of Integrated Team Effectiveness Model: team effectiveness, team process and teams’ psychosocial traits. Due to the resentation of the statements (to what extent something affects teamwork), the subscales apparently are comprised of the items with regard to the organisational context and task design.
We purposefully chose Integrated Team Effectiveness Model to develop and test an instrument that facilitates discussion within a multidisciplinary team about the con-ditions and effectiveness of their teamwork. Integrated Team Effectiveness Model includes factors that influence team function and the ability of teams to perform effec-tively by obtaining clearly defined measures to questions at the practice, organisational and systems level [19]. Especially in the field of integrated care, this broad per-spective seems highly relevant. Furthermore, Integrated Team Effectiveness Model dis-tinguishes between objec-tive (whether the goals of the team are achieved) and subjective outcomes (whether the team in itself works well together). This is of relevance considering that for the delivery of integrated care the formation of teams is work in progress [19]. Nonetheless the attractiveness of Integrated Team Effectiveness Model, it is not exhaustive and may therefore miss out on factors or their interrelat-edness in influencing team effectiveness. More research to test the (comparative) power of Integrated Team Effectiveness Model to explain team effectiveness is how-ever needed. In the mean time, the present study has shed new light on the value of Integrated Team Effectiveness Model for healthcare professionals in self-evaluating their
team effectiveness in the delivery of integrated care for people with COPD.
Although the teamwork assessment instrument was developed and tested for validity using mixed methods, this study encountered some methodological limitations. Integrated Team Effectiveness Model assumes that all fac-tors contri-bute to team effectiveness. Nevertheless, there may be different levels of influence. The instrument is not able to assess factors individually or to grade the overall level of effectiveness of teamwork. We believe all items identified by healthcare professionals are important for teamwork. Therefore, each item (except for item 15 ‘the effectiveness of our team meetings is not sufficient’ due to statistical limitations) was included in the factor analysis in spite of low communalities. What is critical here is not the communality coefficient per se, but rather the extent to which the item plays a role in the interpretation of the factor.
In general, items that do not have a factor loading above 0.40 should be dropped from a scale and the instrument [28]. In the current study, the factor analysis aimed to sustain the usefulness of Integrated Team Effectiveness Model for developing a well-founded instrument. The purpose of the developed instrument was to provide a structured basis for a team discussion. For these reasons, a factor loading of 0.35 was regarded as being sufficient; thereby excluding item 9, ‘there are adequate opportuni-ties to increase our knowledge about COPD’. This item does not directly relate to teamwork but rather is an indi-cator of the organisational context. We suggest reformula-tion of this item in ‘opportunities to increase our mutual knowledge about COPD’ in order to improve the connec-tion with teamwork effectiveness.
The wording of other items also needs further improve-ments. Item 15, ‘the effectiveness of our team meetings is not sufficient’, is too vague. Based on the statistical analysis and interpretation, two questions are ambigu-ous as they are loading on different components. For item 21, ‘I feel that we jointly are doing a good job in meeting patients’ care needs’, the reason of loading on the team’s psychosocial traits might be the emphasis on ‘jointly’ that refers to a shared ambition. The double loading of item 19, ‘our communication is characterised by openness’ could be explained by the broad (Dutch) formulation.
able to apply the instrument to their practice. Thus, not only the perspective and experiences of healthcare provid-ers determined the content of the teamwork instrument but also the broader context. This underlines the impact of the sociopolitical context with regard to team-work effectiveness [13, 14, 17].
In developing the Integrated Teamwork Effectiveness Instrument we generated the items and performed a con-firmatory factor analysis in daily practice. For the latter, the sample size of this study was slightly below the rec-ommended number of 200 independent observations. Furthermore, additional testing is necessary to assess other psychometric properties of the Integrated Teamwork Effectiveness Instrument including convergent, discrimi-nant and criterion-related validity [24].
In this study, only the perspectives of the healthcare professionals were examined. As such, the instrument offered a starting point for a team performance interview with all healthcare providers involved. Customers of ser-vices delivered by a team (i.e. patients) should also par-ticipate in the assessment of teamwork effectiveness [16]. Existing instruments for the assessment of teamwork by patients exist in different healthcare and long-term care settings (e.g. [29]), whereas within the field of integrated care such assessment is, if performed at all, often limited to one or a handful of items as part of a more compre-hensive instrument (e.g. PACIC [30]). Use of the Integrated Teamwork Effectiveness Instrument may be followed by the development, validation and use of an instrument for patients. Notwithstanding the importance of the patient as being a member of the team, an improvement of coor-dination and teamwork between pro-fessionals might already benefit the degree to which health care is experi-enced as coherent and connected and con-sistent with the patient’s needs and personal context [31].
The Integrated Teamwork Effectiveness Instrument assumes not to be an exhaustive numeration of deter-minants that affects teamwork effectiveness in COPD care, but it provides team members an instrument for a systematic self-evaluation and a basis for discussions about teamwork. This instrument was developed in the Dutch healthcare setting of integrated COPD care. We believe other teams in the Netherlands and other countries can further test the Integrated Teamwork Effectiveness Instrument. However, the instrument itself may need some contextual adaptation before being tested in other countries. In doing so, this study can serve as a resource to adapt the Integrated Team-work Effectiveness Instrument.
Although the checklist is positively evaluated by the expert panel, this study did not examine the actual use of the instrument in practice. Due to the timing of the second phase of this study (the bundled payment was just intro-duced), practice nurses were not ready for coordinating an evaluation of teamwork. Therefore, the key factors for successful implementation and the contribution as well as the responsiveness of Integrated Teamwork Effectiveness Instrument with regard to the improvement of teamwork effectiveness need further research. Feedback about team
effectiveness may improve the motivation of team mem-bers and energises them for higher performance [16].
A better understanding and measuring of teamwork effectiveness is relevant for collaborative practice. In this study, the Integrated Teamwork Effectiveness Instrument was developed by using the Integrated Team Effectiveness Model. This theoretical model was found applicable to the experiences of healthcare professionals in COPD care. A practical assessment instrument that evaluates teamwork effectiveness could be derived from interviews based on the Integrated Team Effectiveness Model. Healthcare pro-fessionals perceived Integrated Teamwork Effectiveness Instrument as a helpful instrument to assess their col-laborative practice and to structure a dialogue about teamwork. The factor analysis identified three reliable subscales of team effectiveness, which corresponded to domains of Integrated Team Effectiveness Model. This study indicated that the healthcare providers’ perspective on the effectiveness of their teamwork could be translated into a well-founded teamwork assessment instrument. Competing Interests
The authors declare that they have no competing interests. Acknowledgements
We would like to thank Cooperative VGZ and Maastricht University Medical Center for their financial support to conduct this study and all participating healthcare provid-ers for their input.
Reviewers
Birthe Dinesen, Associate professor, PhD, Master in Polit-ical Science, Department of Health Science and Technol-ogy, Faculty of Medicine, Aalborg University, Denmark.
Nina Szczygiel, PhD, Assistant Professor, University of Aveiro, Department of Economics, Management, Industrial Engineering and Tourism, Portugal.
One anonymous reviewer. References
1. Global Burden of Disease 2013 Collaborators. Global, regional, and national incidence, preva-lence, and years lived with disability for 301 acute and chronic diseases in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2015; 386: 743–800. DOI: http:// dx.doi.org/10.1016/S0140-6736(15)60692-4
2. Celli, BR. Update on the management of COPD.
Chest. 2008; 133: 1451–62. DOI: http://dx.doi. org/10.1378/chest.07-2061
3. Wesseling, GJ and Vrijhoef, HJM. Acute exac-erbations of COPD: recommendations for integrated care. Expert Review of Respiratory Medicine. 2008; 2(4): 489–94. DOI: http://dx.doi. org/10.1586/17476348.2.4.489
Van Dijk-de Vries et al: Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD Art. 9, page 9 of 10
Database Systematic Reviews. 2013; 10: CD009437. DOI: http://dx.doi.org/10.1002/14651858.CD009437. pub2
5. Nolte, E, Knai, C, Hofmarcher, M, Conklin, A, Erler, A, Elissen, A, et al. Overcoming fragmentation in health care: chronic care in Austria, Germany and the Netherlands. Health Economics. Policy and Law. 2012; 7: 125–46. DOI: http://dx.doi.org/10.1017/ S1744133111000338
6. Martyn, H and Davis, K. Care coordination for people with complex care needs in the U.S.: a policy analysis. International Journal of Care Coordination. 2014; 17: 93–8. DOI: http://dx.doi. org/10.1177/2053434514559721
7. Plochg, T and Klazinga, NS. Community-based integrated care: myth or must? International Journal for Quality in Health-care. 2002; 14: 91–101. DOI: http://dx.doi.org/10.1093/oxfordjournals.intqhc. a002606
8. Ouwens, M, Wollersheim, H, Hermens, R,
Hulscher, M and Grol, R. Integrated care pro-grammes for chronically ill patients: a review of systematic reviews. International Journal for Quality in Healthcare. 2005; 17: 141–6. DOI: http://dx.doi. org/10.1093/intqhc/mzi016
9. Pinnock, H, Huby, G, Tierney, A, Hamilton, A, Powell, A, Kielmann, T, et al. Is multidisciplinary teamwork the key? A qualitative study of the devel-opment of respiratory services in the UK. Journal of the Royal Society of Medicine. 2009; 102: 378–90. DOI: http://dx.doi.org/10.1258/jrsm.2009.080356 10. Hogg, W, Lemelin, J, Dahrouge, S, Liddy, C,
Armstrong, CD, Legault, F, et al. Randomized controlled trial of anticipatory and preventive multidisciplinary team care. Canadian Family Physician. 2009; 55: e76–85.
11. Atwal, A and Caldwell, K. Do multidisciplinary integrated pathways improve interprofessional collaboration? Scandinavian Journal of Caring Sciences. 2002; 16: 360–7. DOI: http://dx.doi. org/10.1046/j.1471-6712.2002.00101.x
12. San Martín-Rodríguez, L, Beaulieu, M, D’Amour, D and Ferrada-Videla, M. The determinants of successful collaboration: a review of theoreti-cal and empiritheoreti-cal studies. Journal of Interprofes-sional Care. 2005; 19: 132–47. DOI: http://dx.doi. org/10.1080/13561820500082677
13. Canadian Health Services Research Foundation (CHSRF). Teamwork in healthcare: promoting effec-tive teamwork in health-care in Canada. Ottawa: CHSRF. 2006. Available from: http://www.cfhi-fcass. ca/migrated/pdf/teamwork-synthesis-report_e.pdf [cited 24 November 2015].
14. Heinemann, GD and Zeiss, AM. Team performance in healthcare. Assessment and development. New York: Kluwer Academic/Plenum Publishers; 2002. DOI: http://dx.doi.org/10.1007/978-1-4615-0581-5 15. Jansen, L. Collaborative and interdisciplinary
healthcare teams: ready or not? Journal of Professional
Nursing. 2008; 24: 218–27. DOI: http://dx.doi. org/10.1016/j.profnurs.2007.06.013
16. Singh, AK and Muncherji, N. Team effectiveness and its measurement: a framework. Global Busi-ness Review. 2007; 8: 119–33. DOI: http://dx.doi. org/10.1177/097215090600800108
17. Reeves, S, Lewin, S, Espin, S and Zwarenstein, M. Interprofessional teamwork for health and social Care. Partnership working in action. Oxford, United Kingdom: Blackwell Publishing Ltd; 2010. DOI: http://dx.doi.org/10.1002/9781444325027
18. Brennan, SE, Bosch, M, Buchan, H and Green, SE. Measuring team factors thought to influence the success of quality improvement in primary care: a systematic review of instruments. Implementation Science. 2013; 8: 20. DOI: http://dx.doi.org/ 10.1186/1748-5908-8-20
19. Lemieux-Charles, L and McGuire, W. What do we know about healthcare team effectiveness? A review of the literature. Medical Care Research and Review. 2006; 63: 263–300. DOI: http://dx.doi. org/10.1177/1077558706287003
20. Cohen, SG and Bailey, DR. What makes teams work: group effectiveness research from the shop floor to the executive suite. Journal of Manage-ment. 1997; 23: 238–90. DOI: http://dx.doi. org/10.1177/014920639702300303
21. De Bakker, DH, Struijs, JN, Baan, CB, Raams, J, De Wildt, J-E, Vrijhoef, HJM, et al. Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination. Health Affairs. 2012; 31: 426–33. DOI: http://dx.doi.org/10.1377/hlthaff.2011.0912 22. Schulpen, GJC, Vierhout, WPM, Van der Heijde,
DM, Landewé, RB, Winkens, RA and Van der Linden, S. Joint consultation of general practitioner and rheumatologist: does it matter? Annals of Rheu-matic Diseases. 2003; 62: 159–61. DOI: http:// dx.doi.org/10.1136/ard.62.2.159
23. Steuten, L, Vrijhoef, B, Van Merode, F, Wesseling, GJ and Spreeuwenberg, C. Evaluation of a regional disease management programme for patients with asthma and COPD. International Journal for Quality in Healthcare. 2006; 18: 429–36. DOI: http://dx.doi. org/10.1093/intqhc/mzl052
24. Hinkin, TR. A brief tutorial on the development of measures for use in survey questionnaires. Organisational Research Methods. 1998; 1: 104–21. DOI: http://dx.doi.org/10.1177/1094428198 00100106
25. Rabiee, F. Focus-group interview and data analysis.
Proceedings of the Nutrition Society. 2004; 63: 655–60. DOI: http://dx.doi.org/10.1079/ PNS2004399
27. Froman, RD. Elements to consider in planning the use of factor analysis. Southern Online Journal of Nursing Research (SOJNR). 2001; 5: 1–22.
28. Lance, CE, Butts, MM and Michels, LC. The sources of four commonly reported cut-off criteria: what did they really say? Organizational Research Methods. 2006; 9: 202–20. DOI: http://dx.doi. org/10.1177/1094428105284919
29. Orchard, CA, King, GA, Khalili, H and Bezzina, MB. Assessment of Interprofessional Team Collaboration Scale (AITCS): development and testing of the instru-ment. Journal of Continuing Education in Health
Professions. 2012; 32: 58–67. DOI: http://dx.doi. org/10.1002/chp.21123
30. Glasgow, RE, Wagner, EH, Schaeffer, J, Mahoney, LD, Reid, RJ and Green, SM. Development and valida-tion of the Patient Assessment of Chronic Illness Care (PACIC). Medical Care. 2005; 43: 436–44. DOI: http:// dx.doi.org/10.1097/01.mlr.0000160375.47920.8c 31. Haggerty, JL, Reid, RJ, Freeman, GK, Starfield, BH,
Adair, CE and McKendry, R. Continuity of care: a multidisciplinary review. British Medical Journal. 2003; 327: 1219–21. DOI: http://dx.doi.org/10.1136/ bmj.327.7425.1219
How to cite this article: Van Dijk-de Vries, A N, Duimel-Peeters, I G P, Muris, J W, Wesseling, G J, Beusmans, G H M I and Vrijhoef, H J
M 2016 Effectiveness of Teamwork in an Integrated Care Setting for Patients with COPD: Development and Testing of a Self-Evaluation Instrument for Interprofessional Teams. International Journal of Integrated Care, 16(1): 9, pp. 1–10, DOI: http://dx.doi. org/10.5334/ijic.2454
Submitted: 14 March 2016 Accepted: 03 November 2015 Published: 08 April 2016
Copyright: © 2016 The Author(s). This is an open-access article distributed under the terms of the Creative Commons
Attribution 4.0 International License (CC-BY 4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. See http://creativecommons.org/licenses/by/4.0/.
